Agencies Alarmed by Bhutanese Refugee Suicides

On the morning of April 10, Indra Mainali was running errands in preparation for his daughter's birthday party when he received a frantic phone call from his wife. Indra's father, Hari, had called her and said, "If you want to see me for the last time, come to Ethan Allen Homestead."

When Indra arrived at the Burlington landmark, where Hari had established a garden plot the previous summer, an officer told him his father was dead. Asked how it happened, the officer replied, according to Indra, "He used a rope. We will know more after the postmortem."

Three months later, Hari's family still doesn't know many of the circumstances surrounding his death. The state's chief medical examiner ruled it a suicide by hanging.

"He had a job. He had a car. Why did he do that?" wondered his daughter, Ruk. She and her family moved to Vermont from a refugee camp in Nepal in 2013. Her brothers and parents arrived three years later.

Ruk was helping her sister-in-law prepare food for the party when her father called. Both women pleaded with him to come home. "'I will keep you for your whole life,'" Ruk said she told him. "But he didn't listen to us."

Bhutanese refugees resettled in the U.S. are twice as likely to die by suicide as members of the general population, according to a report published by the U.S. Centers for Disease Control and Prevention in 2012. That report covered 16 deaths reported in 10 states between 2009 and 2012, none of which were in Vermont. But the local landscape has since changed.

Hari, 52, was the second local Bhutanese refugee to die by suicide this year, according to members of that community, which numbers about 2,500. Out of respect for the family's privacy, Seven Days is not naming the other suicide. Data from the Vermont Department of Health show two additional suicide cases involving Bhutan-born individuals, one in 2012 and one in 2016.

"It's just sobering that this is happening after people put in so much effort to get here," said Martha Friedman, the refugee health and health equity coordinator at the health department.

Health providers and social support agencies that work with Bhutanese refugees are concerned about "what seems to be a growing trend," said Friedman. "This is something all of us have a responsibility to be working on."

The U.S. Office of Refugee Resettlement prompted the CDC to investigate suicides among ethnic-Nepali Bhutanese refugees after finding that, from 2009 to 2012, their estimated age-adjusted suicide rate was 24.4 per 100,000 people, nearly twice the rate in the general U.S. population. The CDC's study pinpointed various possible motivations for the suicidal acts, including integration difficulties, family separation, lack of resettlement services and social support, and disappointment with career prospects. All of the suicides studied occurred within a year of arrival in the U.S., and only one of the deceased had ever talked with others about committing suicide.

By all accounts, Hari seemed to have adjusted to his new environment. He worked at a meat processing company, had a garden plot at the Ethan Allen Homestead in summer 2017 and spent his leisure time fishing. Still, he knew little English and lamented that he needed an interpreter for all of his appointments.

"I don't know how he [felt] inside," said his son Indra, "but outside ... he [looked] good."

The Bhutan News Service, an independent agency operated by Bhutanese refugee journalists, kept suicide data for one year after the CDC study ended, then began publishing articles on suicide prevention. In 2015, the website ceased reporting on the topic. Its leadership feared that continual coverage might trigger copycat acts and normalize suicide, explained BNS cofounder TP Mishra, who's based in Charlotte, N.C., in an email.

While the stats may startle some observers, suicide isn't a new issue for the Bhutanese refugee population. "There was a high suicide rate in the camps," pointed out Rochelle Frounfelker, a social epidemiologist working in global mental health. The postdoctoral fellow in McGill University's social and transcultural psychiatry division is overseeing a research project at Harvard University on the mental health of older Bhutanese refugees in greater Springfield, Mass.

Refugees in general are at an elevated risk for developing psychological problems for reasons such as their exposure to trauma and the conditions they encounter in their third-country resettlement, said Frounfelker. But suicide is "pretty unique" to the Bhutanese, she continued; no body of literature exists on the issue regarding other refugees such as the Bosnians, Vietnamese or Cambodians.

"The reason that it became on the radar of the CDC is the frequency with which it was happening for that size of the population," she said.

Bhutanese of Nepali descent, also known as Lhotshampas, were stripped of citizenship and expelled from Bhutan in the early 1990s; some experienced torture at the hands of government forces. The Lhotshampas fled to southern Nepal, where they lived in squalid refugee camps for more than 20 years. Resettlement to third countries began in 2008.

All refugees undergo an overseas health assessment before resettlement, said Amila Merdzanovic, director of the Vermont Refugee Resettlement Program. But individuals are unlikely to disclose any medical conditions, especially those related to mental health, because they fear their departure might be delayed, she added.

If properly trained to do assessments, her staff could help bridge that gap in mental health services, suggested Merdzanovic, who was part of a mental health and social adjustment program for refugees in the late 1990s. Case managers already spend considerable time with newcomers and have helped clients receive early intervention, she noted.

While refugees endure significant distress prior to resettlement, migration to the U.S. brings additional stressors caused by factors such as the language barrier, loss of social networks and declining social status. In some families, post-migration challenges have led to domestic violence and substance abuse, noted AALV's Neopaney. She said she's referred several clients to mental health providers for services.

Compounding these challenges is the pressure that newcomers face to achieve economic and social self-sufficiency within a few months of arriving in the U.S. But even economic stability doesn't preclude suicidal behavior, as Hari Mainali's death indicates.

Connecting Cultures is a University of Vermont-affiliated clinic that provides mental health services to refugees, asylum seekers and other New Americans, both newcomers and those who've been in Vermont for decades, said director Karen Fondacaro. When the clinic was established in 2007, staffers spent two years doing outreach work in refugee communities.

"They got to know us as people first," said Fondacaro, "because it can seem very foreign for someone to come into a Western treatment environment." Her staff modifies assessments and treatments based on a client's culture and spirituality, she added.

Stigma around mental illness exists in all societies, and sufferers can have a hard time reaching out. This is especially true in the Bhutanese community, where the concept of mental health is "completely new," said Bhuwan Gautam, a community research specialist who's part of Frounfelker's research team. The understanding of health is generally limited to one's physical well-being, he said.

Most Lhotshampas never had access to primary care in Bhutan, and the refugee camps have limited medical care. Gautam, a former Bhutanese refugee himself, explained that people generally relied on medicinal herbs or sought spiritual comfort by singing religious devotional songs.

Individuals who have psychosis, schizophrenia or bipolar disorder are more easily identified and ostracized, but anxiety, depression and post-traumatic stress disorders are not perceived to be a "big deal" in the Bhutanese community, Gautam said. Family members either don't recognize suicidal behavior or are too preoccupied with their own daily problems to intervene, he added. Barriers to accessing care, such as low health literacy and language and transportation problems, exacerbate the situation.

Education is key, said the Harvard pair and Neopaney. Bhutanese households have their own natural support system, which is based on their collectivist culture, added Gautam, "[but] here everyone is busy, and those natural support systems are not available." Mental health training or first aid sessions might help families recognize warning signs and intervene, he added.

Frounfelker said educating the community about mental health could make people more receptive to seeking help. Mental health and social services providers can coordinate with the community's natural support systems to decrease risks overall, she suggested.

Mental health professionals need to do a better job of assessing risks, said Jonah Meyerhoff, a PhD candidate at UVM who is studying suicide prevention in underrepresented populations. Screening tools for suicide are inadequate in general, he continued, with no single predictor. They're also often based on Anglo-Saxon, Western or European cultures.

For the past year, the PhD candidate has been working on improving the detection of suicide risks among Bhutanese refugees using culturally responsive assessment measures. "We need to look at culturally relevant constructs," said Meyerhoff, citing factors such as cultural sanctions, minority stress and social discord.

To recruit volunteers for his project, Meyerhoff and his research assistant posted flyers in English and Nepali around Burlington and Winooski, which have the greatest concentration of Bhutanese refugees.

"I've been very encouraged in that people want this project done," he said. Though Bhutanese culture tends to frown on the public discussion of suicide and mental health, he added, many locals have been "very willing to help" — when confidentiality is assured — because they care about their community's well-being.

Health and social services providers stress that the issues with which some Bhutanese refugees grapple — isolation, generational conflicts, domestic violence, substance abuse — also exist in other communities across the U.S. At a time when suicide rates are increasing nationally, the resources for supporting such clients too often fall short.

Connecting Cultures has a wait list of three to six months. New American providers who offer screening, brief intervention and referral to treatment services to their respective communities report a lack of acute and crisis services.

Meanwhile, at the national level, the federal government is cutting funding for public and mental health services, and anti-immigrant rhetoric is increasingly prevalent. Under these conditions, providers worry about public insensitivity to the stresses that refugees face. While their resilience may be incredible, it has limits.

For Hari Mainali's family, his death is a sad memory. "Everybody has pain ... get mad," said his son Indra. "Suicide is not a solution."

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